Patient Registration Form - Maine Medical Center

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Person Completing Form: ______________________________________ Relationship to Patient: _______________________ Date: ____________
The information below is required to maintain an accurate patient record and will remain confidential.
PATIENT REGISTRATION FORM
Patient’s Legal Name: Last: _______________________________________ First: ___________________________________ Middle: __________
If patient has had services at MMC under another name please provide it: ____________________________________________________________
Date of Birth: _____________________________
Sex: M______ F______
Social Security Number: __________________________________
Mailing Address: ____________________________________ City _________________________ State ________________ Zip Code___________
Telephone Number: Area code (
) __________________________ Alternate Phone Number: (
) __________________________
Marital Status: (circle one)
Single
Married
Separated
Divorced
Widowed
Life Partner
Race: (circle one)
White
Black/African American
Alaska Native/American Indian
Asian
Native Hawaiian/Other Pacific Islander
Other
Ethnicity: Latino/Hispanic
Yes
No
What is the primary language spoken in home: __________________________________
Language Interpreter:
Yes
No
Sign Language Interpreter:
Yes
No
Is patient hard of hearing:
Yes
No
Is patient deaf:
Yes
No
Does patient need an Assistive Listening Device at time of services:
Yes
No
Are these services covered by the Veteran’s Administration:
Yes
No
Religious Preference: ________________________Spiritual Advisor: ________________________Place of Worship: ________________________
Employment Status: (circle one) Full-Time
Self-Employed
Part-Time
Active-Military
Retired
Not Employed
Disabled
Employer or Employer retired from: _____________________________ Employer’s Telephone Number: Area code (
) __________________
Employer’s Address: ___________________________________ City ___________________________ State ______________ Zip Code_________
Legal Next of Kin or Emergency Contact: Last: _______________________________________ First: _____________________________________
Relationship to Patient: _______________________ Home Phone: _____________________ Alternate Phone Number: _______________________
Patient’s Primary Care Physician (P.C.P) ______________________________________________________________________________________
SPOUSE/LIFE PARTNER/GUARDIAN/PARENT INFORMATION
If patient is a minor (under 18 years of age), please provide infpormation on both parent(s) below.
Spouse/Life Partner/Guardian Name: Last________________________________ First________________________________ Middle Initial ______
Relationship to Patient: ___________________________________ Date of Birth: _______________________________
Sex: M______ F______
Social Security Number: __________________________________ Telephone Number: Area code (
) ________________________________
Mailing Address: ____________________________________ City _________________________ State ________________ Zip Code___________
Employment Status: (circle one) Full-Time
Self-Employed
Part-Time
Active-Military
Retired
Not Employed
Disabled
Employer or Employer retired from: _____________________________ Employer’s Telephone Number: Area code (
) __________________
Employer’s Address: ________________________________ City __________________________ State ________________ Zip Code___________
Guardian Name: Last_______________________________________ First ________________________________________ Middle Initial _______
Relationship to Patient: ___________________________________ Date of Birth: _______________________________
Sex: M______ F______
Social Security Number: __________________________________ Telephone Number: Area code (
) ________________________________
Mailing Address: ____________________________________ City _________________________ State ________________ Zip Code___________
Employment Status: (circle one) Full-Time
Self-Employed
Part-Time
Active-Military
Retired
Not Employed
Disabled
Employer or Employer retired from: _____________________________ Employer’s Telephone Number: Area code (
) __________________
Employer’s Address: ________________________________ City __________________________ State ________________ Zip Code___________
142306+ 7/10 107246
NOT A MEDICAL RECORD

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